Internists' Antidepressant Guideline Defended

by John Gever John Gever,Senior Editor, MedPage Today
November 26, 2008

PALO ALTO, Calif., Nov. 26 -- Responding to criticism from a prominent psychiatrist, the chairman of the committee that developed the American College of Physicians' new practice guideline for second-generation antidepressants offers a rebuttal.

Douglas Owens, M.D., of the VA Medical Center here, said the ACP had no intention of suggesting that anti-depressant drugs are the only depression treatment that primary care physicians need to know about.

He denied that the ACP sent such a message by issuing a guideline that focused only on that type of treatment without addressing other aspects of depression management in equal detail.

The ACP's new guideline, based on an extensive literature review, was issued last week. It said that selective serotonin reuptake inhibitors and other newer antidepressant drugs had comparable efficacy, and treatment decisions should, therefore, be based on side effects, costs, and patient preferences. (See: Internist Group Finds No Efficacy Difference Among Modern Antidepressants)

The guideline was attacked by T. Byram Karasu, M.D., of Albert Einstein College of Medicine in New York, who was lead author of the American Psychiatric Association's current treatment guideline for major depression.

Dr. Karasu said guidelines related to complex disorders such as depression should address those complexities. He said it was inappropriate to focus on a single treatment modality.

Dr. Owens, who chairs the ACP's Clinical Efficacy Assessment Subcommittee, under which the guideline was developed, disagreed.

"Our guideline is in no way meant to indicate, and states to the contrary, that we think this is the only treatment for depression," he said in an interview.

Dr. Owens said the guideline was meant to deal with a common clinical situation, in which the primary care physician has a depressed patient for whom drug treatment appears warranted.

"So then, what are the issues and how can we help in terms of making that decision about which type of drug to use?" he said.

"This guideline is intended for primary care clinicians. They may be in the position of either managing drug therapy that someone else has prescribed or prescribing drug therapy for depression themselves," Dr. Owens said.

He said another reason for focusing on second-generation antidepressants was a practical one.

He said that in developing its practice guidelines, the ACP relies on rigorous evidence reviews funded by outside groups -- in this case the federal Agency for Healthcare Research and Quality.

The AHRQ-sponsored review focused on second-generation antidepressants. "We did not get to determine the scope of the report," Dr. Owens said. "We didn't have an evidence review for other therapies for depression."

He also emphasized that the guideline indicated more than once that other treatments for depression exist but were not addressed in the document.

He noted that the ACP has previously issued separate guidelines on diabetes addressing lipid management, hypertension treatment, and glycemic control.

"If I see a guideline on lipid management in diabetes, I don't think that's all there is to management of diabetes," he said.

"People understand that, because of the depth of the guideline and the rigor of the evidence review . . ., we will focus on one piece of the management of a complex condition."

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